Postoperative pain management in the frail elderly.

1. Prevent predictable pain, such as occurs postoperatively. Anticipatory pain management is particularly important in the elderly, who frequently attempt to "tough it out" without much analgesia. 2. Assume the patient is in pain if the situation is potentially painful, even without verbal complaints. Confused elders may be unable or unwilling to verbalize pain. For example, a confused 90-year-old woman with an acute hip fracture should be treated for pain, even if she does not complain of it. Elders, especially if demented, may not have the usual external "pain behaviors." 3. Do not routinely use antiemetics, especially phenothiazines. The incidence of postoperative nausea and vomiting is probably less in the elderly, and antiemetics are strongly anticholinergic and poorly tolerated in the frail elderly. 5. Do not use IM narcotics at all, except as "rescue analgesia" or when acute pain has subsided. Their high peak, low trough profile leads to a respiratory depression, excess pain cycle which is poorly tolerated in the elderly IV, or even oral, morphine is better tolerated. 6. Use multiple modalities for analgesia; for example, intercostal nerve block and epidural opioids, or IV-PCA and IV NSAIDs. This will enhance analgesia and reduce narcotic toxicity. This is especially important in frail elders, who often tolerate systemic narcotics poorly. 7. Use site-specific analgesia. Certain operative sites, such as the upper extremity, are especially amenable to local nerve blocks. Others, such as thoracotomy, are especially painful and need potent analgesia. For upper-extremity surgery, consider interscalene nerve block and NSAIDs. For thoracotomy, use extrapleural, intercostal nerve block and epidural narcotics. Local bupivacaine and NSAIDs work well after inguinal herniorrhaphy. For knee surgery, consider intra-articular morphine and NSAIDs. 8. Whenever possible, add a scheduled parenteral, rectal, or oral NSAID, in order to spare narcotics, enhance analgesia, and decrease inflammatory mediators. Unless the patient has a contraindication or there is a strong concern about hemostasis or peptic ulceration, NSAIDs should generally be administered. The major concern in frail elders is acute renal failure; therefore, ensure good hydration and avoid use of NSAIDs if renal function is diminished. NSAIDs should be used on a scheduled (not prn) basis.

The dwindles: failure to thrive in older patients.

Geriatric failure to thrive has three elements: (1) deterioration in the biologic, psychologic, and social domains; (2) weight loss or undernutrition; and (3) lack of any obvious explanation for the condition. It results from the combined effects of normal aging, malnutrition, and specific physical, social, or psychologic precipitants (e.g., chronic disease, dementia, medication, dysphagia, depression, or social isolation). Failure to thrive can be managed with a common sense approach by primary care physicians and health care providers such as social workers and dietitians; extensive referral is not necessary. The key to effective care is to identify all of the precipitants and intervene early enough to prevent progression.

'The dwindles'. Failure to thrive in older patients.

Geriatric failure to thrive has three elements: deterioration in the biological, psychological, and social domains; weight loss or undernutrition; and lack of any obvious explanation for the condition. It results from the combined effects of normal aging, malnutrition, and specific physical, social, or psychological precipitants (eg, chronic disease, dementia, medication, dysphagia, depression, social isolation). Failure to thrive can be managed with a commonsense approach by primary care physicians and healthcare providers such as social workers and dietitians; extensive referral is not necessary. The key to effective care is to identify all of the precipitants and intervene early to prevent progression.

The older alcoholic: recognizing the subtle clinical clues.

Alcoholism is a common disease in older patients, affecting up to 10% of those living at home and as many as 40% of those in nursing homes. Symptoms tend to be nonspecific, including "failure to thrive," insomnia, diarrhea, and dementia. Morbidity and increased mortality can occur with no more than one or two drinks daily, because of altered pharmacokinetics with aging. Recognizing alcohol-induced brain injury, which can resemble Alzheimer's disease, is particularly important in the management of older patients. Withdrawal is more severe and prolonged than in younger patients and may require the judicious use of benzodiazepine therapy.

Effects of patient-controlled analgesia on postoperative anxiety in elderly men.

OBJECTIVE: To determine whether the use of patient-controlled analgesia vs intramuscular injections improves postoperative psychological parameters, particularly anxiety. DESIGN: Randomized, controlled trial of patient-controlled analgesia vs as-needed intramuscular morphine with pre- and postoperative assessments of pain, mental status, narcotic use, anxiety and mood states. SETTING: General surgical wards and surgical intensive care unit at a Veterans Administration hospital. PATIENTS: Eighty-three elderly, chronically ill males undergoing major elective surgery. INTERVENTION: Subjects randomized to receive postoperative patient-controlled analgesia vs as-needed intramuscular morphine. Pre- and postoperative assessments of State-Trait Anxiety Inventory, McGill-Dartmouth Part IV and Short Portable Mental Status Questionnaire. Pain (using linear analog scale), sedation score and narcotic use assessed every 4 hours for 72 hours. RESULTS: No differences were found in state anxiety or self-perceived mood states. Postoperative state anxiety was found to relate most closely to preoperative anxiety and postoperative complications, rather than method of analgesia or severity of pain. However, patient-controlled analgesia subjects had significantly improved analgesia and increased satisfaction. CONCLUSION: The use of patient-controlled analgesia does not significantly alter the measured psychological parameters, compared with intramuscular injections. Improved analgesia is the result of pharmacologic effects, independent of psychological factors.

Gallstone symptoms. Myth and reality.

Gallstones are very common, but at least two thirds of detected stones are asymptomatic and a large number undoubtedly go undetected. The presence of symptoms or complications is the indication for surgery. It is important to accurately identify which symptoms are caused by gallstones, because removing the gallbladder will relieve only these symptoms. Making this determination is a challenge, however, because the classic picture of biliary colic may be inaccurate and the connection between gallstone disease and flatulent dyspepsia is questionable at best. Descriptions of both these conditions are based on anecdotal evidence or reports of uncontrolled surgical series. A review of recent controlled trials suggests that the pain of biliary colic is constant and infrequent, comes in episodes lasting 1 to 5 hours, is located in the epigastrium or right upper quadrant of the abdomen, and characteristically occurs at night. There are few additional symptoms other than nausea or vomiting, and colic is not induced by eating fatty meals. Flatulent dyspepsia--a symptom complex of vague pain in the right upper quadrant, fatty-food intolerance, and bloating--is probably not related to the presence of gallstones in the majority of patients.

Help for the hurting elderly. Safe use of drugs to relieve pain.

Pharmacologic management of pain in elderly patients is a common and difficult clinical problem. Because of altered drug metabolism and pharmacodynamics in the elderly, the drugs of choice are different than in younger patients and side effects occur more often. However, with judicious use and monitoring for toxicity, oral medications given as part of a multimodality approach can achieve adequate analgesia in most elderly patients.

Randomized trial of postoperative patient-controlled analgesia vs intramuscular narcotics in frail elderly men.

Postoperative use of as-needed intramuscular narcotics is potentially hazardous in frail elderly patients. Patient-controlled analgesia (PCA) allows patients to self-administer small boluses of narcotic, allowing better dose titration, enhanced responsiveness to variability in narcotic requirements, and reduction in serum narcotic level fluctuation. Although theoretically useful, this method has not bee well studied in the elderly or medically ill. A prospective controlled trial among 83 higher-risk elderly men after major elective surgery compared PCA containing morphine sulfate with intramuscular morphine injections as needed (mean [+/- SD] age, 67.4 +/- 5.6 vs 67.0 +/- 6.3 years). Subjects had a variety of medical illnesses, including chronic lung disease (57%), coronary artery disease (43%), heart failure (13%), and liver disease (12%). Preoperative and postoperative assessments included chest roentgenograms; daily mental status and pulmonary function testing; twice-daily serum morphine levels; and oxygen saturation values, linear analogue pain and sedation scores, and vital signs every 2 hours. Care was taken to optimize narcotic administration in control subjects as well as PCA subjects. Analgesia was significantly improved by PCA (3-day mean pain score, 40.5 +/- 18.0 vs 32.5 +/- 15.0), without an increase in sedation. Significant postoperative confusion (18% vs 2.3%) and severe pulmonary complications (10% vs 0%) occurred significantly more frequently in intramuscular-treated controls. Patient-controlled analgesia was quickly mastered by most patients; no major problems referable to its use occurred. Patients who had previously received intramuscular injections reported that PCA was easier to use and provided better analgesia. Serum morphine levels showed significantly less variability on postoperative day 1 with PCA, compared with intramuscular injections. We conclude that PCA is an improved method of postoperative analgesia in high-risk elderly men with normal mental status, compared with as-needed intramuscular injections.

Medicating the postoperative elderly: how do nurses make their decisions?

Studies show that pain management in postoperative patients often results in undertreatment of pain. Because elderly postoperative patients receive less of the prescribed narcotic dose than their younger counterparts, there may be significant undertreatment of pain. Elderly patients receive less than one fourth of the prescribed narcotic in the first 24 hours after surgery. Type of surgery and vital signs were the factors most frequently used by nurses in their narcotic administration decisions for patients over age 60. According to the study, the factor of age did not appear to be important in the narcotic administration decisions of nurses.

When alcoholics drink aftershave: a study of nonbeverage alcohol consumers.

A one-year prospective study was conducted to describe nonbeverage alcohol (NBA) consumption (the use of substitutes for traditional forms of ethanol) among alcoholics. It was found that 11% of inpatient alcoholics at a veterans' hospital and 8.6% of alcoholics at a community hospital had consumed NBA. Substances consumed ranged from toiletries to organic solvents, often in quantities exceeding the theoretical lethal dose. 'Ready availability' was cited as the primary reason for consumption. Social, demographic and psychiatric parameters were then compared between 48 VA alcoholics who used NBA and 48 nonusing alcoholics. No social or demographic differences were found, but NBA drinkers drank more alcohol (P less than 0.0001), had higher global alcoholic severity scores (P less than 0.0001), more severe withdrawal symptoms (P less than 0.0001), and a higher frequency of antisocial personality disorder (P = 0.009) and drug abuse (P = 0.005). When NBA drinkers were subdivided by quantity of NBA consumption and recency of latest ingestion, no social or psychological differences were found between groups, except for more frequent and heavier illicit drug use among 'heavy' NBA consumers (P less than 0.0001).

Alcoholics who drink mouthwash: the spectrum of nonbeverage alcohol use.

Nonbeverage alcohol (NBA), or substitutes for traditional forms of beverage alcohol, includes such substances as mouthwash, aftershave lotion and alcohol-based fuels. Literature pertaining to the prevalence, clinical significance and toxicity of this practice is reviewed, using illustrative cases from a series of 48 NBA consumers. It was found that 10-15% of alcoholics hospitalized in detoxication units have consumed NBA; half of these patients are regular consumers. Addiction to NBA itself may occur. Its use is primarily related to easy accessibility, rather than social or monetary factors. Polydrug misuse and antisocial personality disorder are more frequent in NBA users, but use is not pathognomic of end-stage alcoholism. The 48 NBA users reported surprisingly few toxic symptoms from acute ingestion, perhaps because tolerance to some substances in NBA may occur. Isopropyl alcohol was the exception, reproducibly causing symptoms suggestive of severe gastritis.